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MEIJER PHARMACY #310
CAH231320-00 Trinity Health Shelby Hospital
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Covered Entity Details
Entity Name
Trinity Health Shelby Hospital
Subdivision Name
Type
Critical Access Hospital
340B ID
CAH231320-00
Entity Address
72 SOUTH STATE STREET
SHELBY, MI 49455
Medicare Provider Number
231320
Participating Start Date
8/9/2010
Last Recertification Date
8/19/2024
Pharmacy Details
Pharmacy Name
MEIJER PHARMACY #310
Pharmacy Address
4665 S GREEN AVE
FREMONT, MI 49412
Pharmacy Comments
Contract Details
Approval Date
4/9/2019
Contract Begin Date
7/1/2019
Carve-In Effective Date
Contract Comments
Contract Termination Date
Termination Reason
1/13/2025
Business decision by covered entity and/or pharmacy
Contacts
Covered Entity Signing Official
John Thomas Foss, Vice President of Operations - Lakeshore Campus
(231) 861-3029
Contract Pharmacy Representative
Meijer
Kevin Hurn, Dir, Pharmacy Procurement and New Business
(616) 791-5185
Signed By Date
4/9/2019
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